Conversation Analysis · perspectives stress four main features of actions that pose immensely challenging issues for the ... The contextual variation (and specification) of action

Conversation Analysis

1. Learning Objectives After reviewing this chapter readers should better be able to:

• Introduce researchers in medicine to the nature and methods of conversation analysis;

• Describe the main dimensions of conversation analytic research in medical practice;

• Describe some of the findings of conversation analysis in the context of primary care;

• Illustrate the practice of conversation analytic reasoning using medical data; and

• Describe the integration of qualitative and quantitative analysis within conversation

analysis.

2. Introduction

Conversation analysis (CA) is the dominant contemporary method for the analysis of social

interaction. Originating at the University of California during the 1960s (Sacks, 1992), the field

has a broad interdisciplinary reach, and is used to study interaction in many languages on an

effectively worldwide basis.

CA begins from the notion that conversational interaction involves 'doing things with words,' and

that, for example, describing, questioning, agreeing, offering and so on are all examples of

social actions that we use words to perform. It developed from social science perspectives that

recognized the fundamental nature of human action and interaction in the formation and

management of personal identity, social relationships, and human institutions. These

perspectives stress four main features of actions that pose immensely challenging issues for the

systematic analysis of social life. CA was developed specifically to deal with these four issues:

1. Human actions are meaningful and involve meaning-making.

2. Actions are meaningful and make meaning through a combination of their content and

context.

3. To be socially meaningful, the meaning of actions must be shared (or intersubjective).

This sharing may not be perfect, but it is normally good enough for the participants to

keep going.

4. Meanings are unique and singular. Actions function in particular ways to create

meanings that are also particular.

The term 'conversation analysis' reflects the origins of the field in

studies of everyday casual conversation, but CA is also used to study

many more specialized forms of communication including interaction in

educational, legal, political, mass media, and medical settings.

2. Introduction

Human actions are meaningful and involve meaning-making

Human actions (whether spoken or otherwise) are meaningful. Unlike the processes of the

physical universe, they are goal-directed and based on reasoning about the physical and social

circumstances that persons find themselves in. This reasoning involves knowledge, socio-

cultural norms and beliefs, and a grasp of the goals and intentions of others. Because goals,

intentions, and the 'state of play' in interaction can change rapidly, this knowledge and

reasoning is continuously updated, during the process of interaction itself. Social interaction also

involves meaning-making. Actions, no matter how similar or repetitive, are never identical in

meaning. Each of them is singular, if only because it takes place in a new and singular situation.

For example, the actions making up even the most routine of medical visits conducted by an

experienced primary care physician are never identical: they involve unique meaning-making by

particular human beings in a situation that has its own singular history and context. Somehow

this is all being managed, for the most part, through spoken interaction.

Each action therefore is, in some degree, creative in the meaning it

creates and conveys.

2. Introduction

Actions achieve meaning through a combination of their content and context

Self-evidently most spoken actions embody specific language content, describe specific

circumstances, and implement specific actions just by virtue of the creative power of language.

However to this creativity of content must be added the creative power of context. The meaning

of even the most formulaic of actions (such as "okay," 'mm hm" and so on) is in fact,

differentiated by their context.

Analysis of action cannot avoid this contextual variation without appearing superficial and

irrelevant, not least because human beings exploit context in the construction of action.

'Context' is complex and layered. It embraces the immediately preceding action (someone just

said or did something you have to respond to), through medial (for instance, that someone is an

older patient), to distal (for instance, that this must all be accomplished within a new managed

care regime).

To be socially meaningful, the meaning of actions must be shared

Human actions are socially meaningful only to the extent that their meaning is shared by the

actor, the recipient(s) of the act, and (sometimes) other observers. Absent this and actions will

be unintelligible to others and will fail to achieve their desired objectives. The shared meaning of

actions is made possible by the common use of methods for analyzing actions-in-context.

The contextual variation (and specification) of action is a profound

feature of human socio-cultural life, and a second major source of

creativity and meaning-making in interaction that works in tandem

with the creative power of language.

This means that there must be procedures for persons to check

whether their understandings about the meanings of earlier actions

are correct, and of whether their responses are 'on target.'

As persons construct interaction on an unfolding sequence of moves, they will also have to keep

score of 'where they are' in the interaction and of the interaction's 'state of play.' Like 'context,'

shared (or 'intersubjective') meaning is also layered on a gradient from the most public (I asked

you a question and you replied “No”), to less public but available to some observers (your

response betrays the fact that you are not an expert on that condition), to more private (your

”No" is rationalizing an unstated anxiety, or reflects a private promise you made to someone

else).

2. Introduction

Meanings are unique and singular. Actions function in particular ways to

create meanings that are particular.

Implicit in the first three principles is the idea that actions and their meanings are highly

particularized.

A key to this working can be glimpsed in the contrast between the number of colors that are

perceptible to the average human (around 7.5 million) and the basic color terms used by the

average speaker of a language (between 8 and 11). Somehow all that particularity is being

conveyed by very general descriptive terms (red, yellow, etc.). The key to the process is that

most description takes place in plain sight of the colored object ("the guy in the red sweater,"

"the blue humming bird") and the color term can do its job by being amplified and particularized

by its context ("this red would work better than that one").

The four features of action described so far have been discussed within the fields of

anthropology and sociology for about 150 years, where they have mainly been considered as

potential constraints on, or obstacles to, a natural science of society. Nonetheless, these are the

characteristics that a conception of interaction must come to terms with. Social participants

somehow manage their interactions in daily life while coping with, and in fact actually exploiting,

these characteristics of human conduct. Conversation analysis is a discipline that was developed

to come to terms with, and model, these capacities.

At first sight the extraordinary singularity of human action would seem

inimical to any sustained achievement of coherent meaning. Yet it

works – somehow!

Context elaborates the meanings of utterances. A similar principle

applies in interaction: "Is it serious?" is understood differently in the

context of a sprained ankle and a cancer diagnosis.

3. Basic Principles of CA

Sequence

The foundational principles of CA tackle these four fundamental facts of human action by

exploiting the concept of sequence (Schegloff, 2007). The basic idea is actions are

simultaneously context shaped and context renewing. Current actions invite (and in some cases,

mandate) responses, and in turn form the most basic and proximate context in which a next

turn at talk occurs and should be understood. It is a default assumption in human conduct that a

current action, should be, and normally will be, responsive to the immediately prior one. Indeed

persons have to engage in special procedures (e.g., "Oh by the way...") to show that a next

action is not responsive to the prior.

The inherent turn-by-turn contextuality of conversation is a vital resource for the construction of

understanding in interaction.

Since each action will be understood as responsive to the previous one,

the understanding that it displays is open for inspection.


Example 1: Complaint vs. Invitation

The sequential logic inherent in these examples is central to the construction of human

interaction as a shared sense-making enterprise, regardless of its social context. Because it is

the foundation of courses of conduct that are mutually intelligible, this logic underwrites both

the conduct of social interaction and its analysis.

Exercise 1: Characteristics of Human Action


Practices

CA investigates interaction by examining the practices that participants use to construct it.

Example 2: Conversational Practices

Here are three examples of conversational practices:

(a) Turn-initial address terms designed to select a specific next speaker to respond: (Lerner,

2003)

A: Gene, do you want another piece of cake?

(b) Elements of question design that convey an expectation favoring a 'yes' or a 'no'

answer: in this case the word 'any' conveys an expectation tilted towards a 'no.' (Heritage

et al., 2007)

Doc: Do you have any other questions?

(c) Oh-prefaced responses to questions primarily conveying that the question was

inapposite or out of place: (Heritage, 1998)

Ann: How are you feeling Joyce?

Joy: Oh fine.

Ann: 'Cause- I think Doreen mentioned that you weren't so well?

A 'practice' is any feature of the design of a turn in a sequence that (i) has a

distinctive character, (ii) has specific locations within a turn or sequence, and

(iii) is distinctive in its consequences for the nature or the meaning of the

action that the turn implements.


Validation of Practices

Within CA methodology, the significance of these practices is validated internally: that is, by

reference to the actions of the parties. The researcher may look at the frequency of particular

types of response, at the occasions when a practice is used, or at more subtle turn-internal

patterning. For example, if the use of address terms selects next speakers, the addressed

persons should normally speak next and if other than the selected speaker responds, that

should be associated with some difficulty no matter how momentary. If the word 'any' is built to

convey the expectation that a response will likely (or even ideally) be negative, then it should be

liberally found in contexts where that is the case. For example in the physician's first and third

questions in the datum below, it is clear that 'other medical problems' and 'lung disease' are

being treated both as undesirable and as unlikely in this case:

Doc: And do you have any other medical problems?

Pat: Uh No

(7 seconds of silence)

Doc: No heart disease?

Pat: ((cough)) No

(1 second of silence)

Doc: Any lung disease as far as you know?

Pat: No

Finally, if an oh-prefaced response to a question treats the question as inapposite, then we

would expect it to occur in places where that is the case, and we would expect, under certain

circumstances, the questioner to defend the relevance of the question. In the previous

illustrative case, Ann, having asked for an update on a known condition (with 'How are you

feeling?'), hears Joyce's response as questioning its relevance (Robinson, 2006). She then

proceeds to defend her question by reference to what she has heard from a third party

(Doreen).

Neither doctors nor patients abandon these ordinary conversational practices at the door of the

clinic. Rather, these everyday practices of meaning making and action construction fully inhabit

the medical interview, albeit with some modifications and adjustments. Knowledge of their

workings is of considerable importance to the analysis of medical communication, especially

when they are associated with significant and sometimes unrecognized consequences for the

participants and for medical outcomes (Heritage and Maynard, 2006).

The fact that practices of conversation have known meanings and

implications, and are associated with specific effects that are validated

by data-internal analysis is of central significance to the study of

medical communication.


Organizations

The practices that CA finds in interaction cluster around fundamental orders of conversational

and social organization. Detailing these is beyond the scope of this contribution. Suffice it to say

that some are clearly central to the management of interaction itself. For instance, there are:

• Clusters of practices that are associated with taking a turn at talk;

• Practices of repair that address systematic problems in speaking, hearing and

understanding talk; and

• Practices associated with the management of reference to persons and objects in the

world (Schegloff, 2006).

Other organizations of practices address more broadly social dimensions of interaction: a

substantial number of practices are associated with the management of ties of social solidarity

and affiliation between persons, favoring their maintenance and militating against their

destruction; yet others are associated with the management of epistemic rights to knowledge

between persons which is an important dimension of personal identity (Heritage, 2008).

Exercise 2: Important Analytic Tool

4. CA and the Medical Encounter

Levels of Analysis

CA approaches the medical visit at several levels of analysis, which can easily be seen in the

acute primary care visit.

1. Overall phase structure

2. Sequence Organization

3. Turn Design

4. Lexical Choice

Overall Phase Structure

At the broadest level is the overall structure of the visit. This has been institutionalized in

American medicine since the 1880s and taught in medical school, and has been learned

inductively by patients ever since. An ideal model of this structure, recognizable to clinicians and

patients alike is represented below.

Figure 1: Phase Structure of the Acute Care Primary Visit

Phase Structure of the Acute Care Primary Visit (Based on: Byrne and Long, 1976)

As Byrne and Long (1976) note, this structure is idealized: many visits embody departures from

this organization (Robinson, 2003). However its value does not lie in its capacity for exact

representation of the events of the medical consultation, but rather in the ways it supplies the

participants with a normative road-map or schema of how medical visits normally run. With the

use of this schema, the participants can orient themselves to:

• Recognizable landmarks in the visit;

• The relevancies that come into play during particular phases;

• Appropriate and expectable conduct given a particular phase; and

• What may be expected to happen next.

This orientation is highly visible at phase boundaries, where phase transition is imminent or

contested (Robinson and Heritage, 2005; Robinson and Stivers, 2001).


Sequence Organization

At the next level down is sequence organization which, as previously noted, concerns how

sequences of actions are put together. For example much of primary care question-answer

sequences are punctuated by clinician acknowledgements that indicate a willingness to see the

patient continue with a response (such as "yes" or "mm hm"), or, alternatively,

acknowledgments that indicate a preparedness to shift to some new topic, or activity (such as

"okay" or "right"). Because of these differences in inviting sequence expansion or sequence

closure, these acknowledgments have the effect of compiling questions into topical 'blocks,'

treating their topics as remaining to be further clarified or, alternatively, as closed.

Example 3: Physician-initiated Sequence

For example, in the following pediatric history, the clinician treats the mother's initial

response to his question as sufficient (line 4) but, following her elaboration, he does not

intervene again until line 9 when he pursues the matter of how the child's cough sounds.

After his subsequent question at line 12, he boundaries off the mother's inconclusive

response (at line 17), and then resets the terms of his question at line 19, finally gaining a

clear response.

Physician-initiated sequences in medicine can vary significantly in terms of the conditions under

which they may be closed. Clinicians can proceed from diagnosis to the treatment plan without

the necessity of explicit acknowledgement of these findings by the patient (Heath, 1992;

Peräkylä, 1998; Stivers, 2007). This observation, however, does not apply to the treatment

plan: it is difficult to leave the treatment phase of a medical encounter without some overt sign

of acceptance by the patient, and this can be exploited by patients who can and do deploy a

form of 'passive resistance' to medical recommendations as a means of influencing clinicians to

revise the treatment plan (Stivers, 2005, 2007).


Example 4: Perspective Display Sequence

In a study of informing interviews with parents of children who have been tested for mental

disabilities, Maynard (2003) describes the use of a 'perspective display' sequence in which

clinicians begin by asking the parents for their view of their child's condition, as in the

following example (Maynard, 1992). At line 1, the clinician asks the child's mother for her

view of the child's condition, eliciting a response that acknowledges the existence of

language difficulties (lines 3-7).

The significance of this prefatory solicitation is that it enables clinicians to anticipate the

stance that the parent has to the child's condition. Stances that may emerge in the form of

resistance or denial can be anticipated and addressed. Moreover the perspective display

sequence also allows physicians where possible, to build their clinical judgments as in

agreement with the parent's conclusions (see lines 13-16 above). An important outcome of

this process is that the parent may be better prepared for adverse conclusions (Maynard,

1996, 2003).


Turn Design

At a further level of detail, the actions that are built into sequences must be implemented in

turns at talk.

Example 5: Turn Design

Early in a British community nurse's first home visit to a primiparous mother, the nurse,

apparently noticing the baby chewing on something, initiates the following exchange Drew

and Heritage (1992):

Here the nurse's comment attracts very different responses from the child's parents. The

father's turn is entirely occupied with agreeing with the nurse's observation. The mother's

response however, by treating the nurse as implying that her child is hungry, embodies a

defense against this implication and is infused with laugh particles which are often

associated with such responses (Haakana, 2001).

Turns are the objects of design and selection which are communicative and

revealing.

Similarly in the following sequence, which occurs less than a minute later in the encounter,

the following occurs (Drew and Heritage, 1992):

While both husband and wife design their responses as agreements with the nurse at the

arrowed turns, the design of those agreements is quite different. The father (lines 6 and 8)

agrees with reference to their own child, and indicates that they have started to notice the

rapid development that the nurse mentions. The mother is more guarded. She makes no

reference to her own child, confining her agreement to the learning capacities of children in

general.

It is tempting to suggest that a relatively conventional sex-role division of labor informs

both of these sequences. The father, who may have little responsibility for the day to day

care of the child, is inclined to agree in an open-hearted way with the nurse, and even to

claim a little credit for having noticed things that the nurse – the accredited 'baby expert' –

comments on. The mother, with overall responsibility for the child, may encounter the

nurse's expertise as a threat to her own, and to resent the 'surveillance' that is the

unavoidable concomitant of a series of home visits (Heritage and Sefi, 1992).


Turn Design in Problem Presentation

In the context of problem presentation, turn design can have very significant consequences.

Patients can format a concern by only describing symptoms, or by offering a candidate diagnosis

(Stivers, 2002):

As Stivers shows, these two practices for presenting a problem differ in the extent to which they

indicate doubt about a condition and its treatment. 'Candidate diagnoses' anticipate the medical

investigation to come, and may already anticipate treatment outcomes (Stivers et al. 2003) in a

way that 'symptoms only' presentations do not.


Turn Design in History Taking

Physician questions are likewise replete with differences in levels and types of presupposition –

compare "What kind of contraception do you use?" with "Are you using any contraceptives?"

They also vary in terms of whether questions are tilted, for example to promote positive medico-

social outcomes in sequences of 'optimized' questioning (Boyd and Heritage, 2006).

Example 6:

In the following case the patient presented with upper respiratory symptoms:

Or whether, conversely, they anticipate the confirmation of adverse medical signs in

sequences of questions which (Stivers, 2007) labels 'problem attentive' as in the following

case in which the patient presented with flu symptoms:

In contrast to the previous example, each of these questions is geared towards an

affirmative, and problematic, response and is sensitive to the symptoms with which the

child presented.


Lexical Choice

Turns are, of course, made of words, and word selection is a significant feature of turn design.

Thus patients may elect to formulate time references in terms of calendrical 'clock' time, or in

biographical terms.

Example 7: Biographical Reference Point

In the following well-known example, the patient has disclosed extensive and regular

drinking prior to going to bed (Mishler, 1984):

Here the patient's use of a biographical reference point in her response to the physician's

questions first question clearly implicates her marriage as a causal factor in her drinking,

though without saying so explicitly. The clinician pursues a quantitative estimate in his

second question, and the patient complies with a calendrical formulation ("Four years.").


A rather different issue of lexical choice is evident in the next example. Here a mother is

presenting her eleven year old daughter's upper respiratory symptoms. The time is Monday

afternoon, and the daughter has not attended school. The mother begins with a diagnostic claim

(lines 1-2, 5) which strongly conveys her commitment to the veracity of her daughter's claims

about her symptoms, and may imply the relevance of antibiotic treatment (Stivers, 2002;

2007).

The clinician begins to take a history at line 18 and, in the absence of a response from the child

patient, the mother asks when her daughter "noticed" her symptoms. This verb conveys a quite

distinct notion of attention and cognition. It suggests that the child's perception of her

symptoms emerged in an unlooked for and, hence, unmotivated way. Its use is one of several

ways in which the mother conveys her commitment to the factual status of her daughter's

symptoms, and especially works against any possibility that they were fabricated as a means of

not attending school -- an issue that can hang heavily over Monday visits to the pediatrician!

Subsequently the mother distinguishes between the child's noticing her symptoms and

”mentioning” them - thus opening up the possibility that the child has endured them for longer

than 24 hours, which would further underwrite the unmotivated nature of their discovery and

report. Here then what is at issue is how the 'discovery', and the process of the coming to

recognize, 'medical symptoms' is to be portrayed (see Halkowski (2006) for an extended

discussion of this subject).

Here then, are four broad levels at which the analysis of doctor-patient

interaction can proceed. Each one is significant and consequential for

the meaning-making process that is the medical encounter.

• Overall phase structure

• Sequence organization

• Turn design

• Lexical choice

The four levels are nested within one another and in practice all four

levels may be involved in the analysis of actual episodes of interaction.

Exercise 3: Conversation Analysis

5. CA in Action

In this section, the reader will find an illustration of what a CA treatment of a sequence in

doctor-patient interaction looks like. The sequence to be analyzed concerns smoking and

drinking, and forms a part of comprehensive history taking. The participants are an internist and

a middle aged female patient who is divorced with a daughter in her late twenties. The patient is

the owner-manager of a restaurant, has recently gained some weight, and is hypertensive.

Example 8: CA in Action

The exchange goes as follows:

5. CA in Action

Example 8a: CA in Action

In what follows we can examine a series of sub-sequences in this passage of interaction.

01 Doc: tch D'you smoke?, h

02 Pat: Hm mm.

03 (5.0)

04 Doc: Alcohol use?

05 (1.0)

06 Pat Hm:: moderate I’d say

The sequence begins with a “yes/no” (or polar) question about smoking, to which the

patient responds negatively with a brief headshake, and a dismissive "hm mm" (a

minimized version of "no"). At this point, the clinician turns to the question of alcohol. His

initial question "Alcohol use?" is devoid of a verb and is elliptical as between the polar

question "Do you use alcohol?" and the more presupposing "How much alcohol do you use?"

This design allows the clinician to circumvent the "yes/no" question, while permitting the

patient to decide how to frame a response. After a one second silence (a substantial period

of time in an engaged state of interaction) during which the patient assumed a 'thinking'

facial expression, the patient articulates a sound which conveys pensiveness ("hm::"), and

then offers an estimate ("moderate"), concluding her turn with "I'd say" which retroactively

presents her response as an estimate, albeit a 'considered' one. Though presented as a

'considered opinion,' and in scalar terms, the patient's estimate is unanchored to any

objective referent. The scene is now set for a pattern of questioning that will be familiar to

primary care physicians: an attempt to extract a quantitative estimate from the patient.

5. CA in Action

Example 8b: CA in Action

06 Pat Hm:: moderate I’d say

07 (0.2)

08 Doc: Can you define that, hhhehh ((laughing

outbreath))

09 Pat: Uh huh hah .hh I don’t get off my- (0.2) outta

10 thuh restaurant very much but [(awh:)

The physician begins this effort by inviting the patient to 'define' moderate (line 8). As he

concludes his turn, he looks up from the chart and gazes, smiling, directly at the

patient, and briefly laughs. Laughter in interaction is quite commonly associated with

'misdeeds' of various sorts (Jefferson, 1985, Haakana, 2001). Because the laughter in this

case is not targeted at a single word or phrase but follows the physician's entire turn, it will,

by default, be understood as addressing the entire turn. In this case, it appears designed to

mitigate any implied criticism of the patient's turn as insufficient or even self-serving.

In her reply, the patient begins with responsive laughter (Jefferson, 1979) but does not

continue with a 'definition.' Instead she takes a step back from such a definition to remark:

"I don't get....outta thuh restaurant very much but", and her subsequent development of

this line is interdicted by the clinician. While this remark may be on its way to underwriting

a subsequent estimate, its proximate significance is to convey the context of her alcohol

use, or "how" she drinks. Specifically this remark purports to indicate that her drinking is

‘social’: she does not drink alone in her apartment, nor does she drink on the job. In this

way, the patient introduces a little of her 'lifeworld' circumstances into the encounter,

conveying that her drinking is 'healthy' or at least not suspect or problematic.

5. CA in Action

Example 8c: CA in Action

The next phase of this sequence will be easily recognizable to those who have read Elliot

Mishler's The Discourse of Medicine (1984). In that study, Mishler elaborated a distinction

between what he called the ‘voice of medicine’ preoccupied with objectivity and

measurement, and the ‘voice of the lifeworld’ preoccupied with personal experience. Mishler

depicted these two orientations as frequently in conflict, and so they are here. The clinician

pursues a measurable metric for the patient's alcohol use by asking "Daily do you use

alcohol or:=h". The question invites the patient to agree that she uses alcohol on a daily

basis, thereby permitting her to take a step in the direction of acknowledging a 'worst case

scenario' (Boyd and Heritage, 2006). The movement of the word "daily" from its natural

grammatical position at the end of the sentence to the beginning, has the effect of raising

its salience, presenting a frequency estimate as the type of answer he is looking for. Finally,

the 'or' at the end of the sentence, invites some other measure of frequency, and thereby

reduces the physician's emphasis on 'daily' as the only possible (or most likely) response for

the patient to deal with.

5. CA in Action

Example 8d: CA in Action

At this point in the interaction, the physician and patient are no more than two feet apart.

Yet the patient's response to the question is to ask the physician to repeat it. In his analysis

of these kinds of repeat requests, Drew (1997) observes that they are produced either when

there is a hearing problem, or alternatively, when there is a problem in grasping the

relevance of the talk to be responded to. A hearing problem is out of the question because

of the objective circumstances of the participants, and it is subsequently ruled out by the

conduct of both of them. However a 'relevance' problem is not out of the question. After all

the patient's remark at lines 9 and 10 (that she didn't get out of the restaurant "very

much") was most likely on its way to suggesting that she didn't have many opportunities to

drink. The transition from this implication to an inquiry about whether she drinks on a

"daily" basis may indeed have been somewhat jarring, and difficult to process.

Earlier it was suggested that the parties ruled out a 'hearing problem' as the basis for the

patient’s request for repetition. The physician rules this out when, rather than fully

repeating his previous question, he repeats a reduced form in which only the two most

salient words are left: "daily" and "or." Only a full repeat would have been compatible with a

belief that his patient had not heard him. A drastically reduced repeat like this one conveys,

to the contrary, that he believes she heard him. For her part, the patient confirms this

analysis when she proves fully able to respond to this abbreviated repeat, beginning before

it is even concluded. Here then the objective circumstances of the interaction and the actual

conduct of the parties is compatible with only one interpretation of the patient's "Pardon?":

that it expressed a difficulty with the relevance of the question.

This same difficulty is expressed in a different way when the patient begins to respond. The

response includes "huh uh," a casual and minimizing version of "no" designed to indicate

that "daily?" is far off the mark. It is also prefaced by “oh” which, as noted earlier,

communicates that a question was irrelevant or inapposite (Heritage, 1998).

5. CA in Action

Example 8e: CA in Action

After she rejects the physician's frequency proposal of “daily” as an estimate of her alcohol

consumption, the patient finally comes up with an estimate of her own: "once a week."

However she packages this as an estimate of how frequently she “goes out." This framing

has two consequences. (i) It estimates her actual drinking in an implicit way, leaving it to

the clinician to draw the relevant inference. (ii) It renews her insistence on the social, and

morally acceptable, nature of her drinking, implicitly ruling out, for example, solo drinking

at work, or at night after work.

With lines 15-16, physician and patient have arrived at a compromise: the physician has a

frequency estimate of the patient's drinking, while the patient has been able to retain her

focus on "how" she drinks. At line 17, the physician turns to the patient's chart and starts to

write, subsequently acknowledging the patient's response with a sotto voce "okay" and

terminating the sequence.


5. CA in Action

These different orientations were conceptualized by Elliot Mishler (1984) in terms of the 'voice of

medicine' with its technical priorities, and the 'voice of the lifeworld' with its experiential

grounding. As we observed earlier, Mishler portrayed these two orientations as in conflict with

one another, and this conflict is apparent in this datum. Yet it is a conflict which is virtually

mandated by the positions of clinician and patient. In particular, there may be a special

vulnerability for patients who offer quantitative estimates of their drinking too readily or too

'technically' (e.g., "Twenty units a week."). Patients who are tempted to respond in this manner

may reflect that it could be treated as portraying too great a preoccupation with alcohol

consumption, a preoccupation which is itself suspect and may attract further inquiry. Persons do

not 'talk this way' about alcohol in everyday life and, even in the doctor's office, too radical a

departure from ordinary ways of talking about ordinary concerns may be undesirable (Sacks,

1984).

The transactions of this sequence will be relatively familiar to most

physicians. Physicians need anchored, and preferably quantitative,

information as a basis for clinical judgments. Patients are often

inclined to give more contextualized descriptions.

6. Interactions and Outcomes

From Qualitative to Quantitative Research: Interactions and

Outcomes

The analyses presented in previous sections

are relatively detailed and nuanced. But do

the issues described here demonstrably

matter with respect to medical outcomes?

Common sense would suggest that they do,

but this cannot easily be demonstrated in a

case by case analysis. For example, if we wish

to demonstrate the relevance of interaction for

medical decision making, data on interactional

practices needs to be merged with clinical

information, data about health beliefs and

attitudes, and clinical decisions. All this implies

the creation of coded, quantitative data from

individual cases, involving the sacrifice of

nuance and detail for 'big picture' features of

the interaction which translate across

individual cases. In this process, it is advisable to do careful qualitative conversation analytic

preparation (and to keep the individual cases to hand), so as to retain an awareness of what

was 'lost' in the transition to coded data.

Because the application

of conversation analysis

to medicine is a

relatively recent

phenomenon, the results

of quantitative analysis

are very recent and

comparatively sparse.

Nonetheless they

strongly indicate the

value of the method.

7. Unmet Concerns

Take, for example, the observation made earlier that the word ‘any’ in a yes/no question means

that the question is designed for a ‘no’ answer, as in "Do you have any other conditions that you

know of?" The consequences of this are multiple.

• Clinicians will be understood by patients to be conveying their expectations of a ‘yes’

or ’no’ response by their use, or lack of use, of ‘any.’

• In taking a history for an acute condition, the shift to a ‘no’-inviting question format

may be understood by the patient as indexing a question about a more serious or

consequential symptom (e.g., "Any blood in the stool?").

• In some contexts, patients may be induced to believe that the clinician would actually

prefer the answer to be ‘no,’ as in "Anything else?" towards the end of a fifteen minute

visit.

To test this latter hypothesis in relation to patients' unmet concerns, Heritage et al (2007) asked

clinicians to vary a follow-up question inviting additional concerns at the end of the patient's

presentation of the principal concern. The question was: "Is there something/anything else you

would like to address in the visit today?" They found that, among those who had listed

additional concerns in a pre-visit survey, patients were nearly twice as likely to respond

affirmatively to the "something" version of the question than the "anything" version (90.3% vs

53.1%). Relative to non-intervention cases, the "something" version of the question reduced the

likelihood of patients ending the visit with unmet concerns by 78%, while the outcomes from the

"anything" version of the question could not be statistically distinguished from the control cases.

Consider this…

Consider how the significance of particular interactional practices is validated

within the conversation analysis method. Illustrate your response by reference

to the argument that the word 'any' in a question is tilted towards, and invites,

a 'no' response.

The significance of interactional practices are investigated by (i) looking at how

actions in which they occur are responded to; and (ii) at the contexts in which

these questions are produced.

In the case of the claim that questions containing the word 'any' are tilted

towards a 'no' response, the finding is that (i) persons are more likely to

respond 'no' to questions containing the word 'any' than the same question

with the alternative word 'some,' and (ii) that questions containing the word

'any' are more likely to occur when asked about symptoms that the physician

has no a priori reason to suppose are present, for example in comprehensive

history taking.

8. Prescribing Decisions

CA techniques have been extensively employed in studies of antibiotic prescribing decisions by

Stivers, Mangione-Smith and colleagues. The background of these studies is that physicians'

perceptions of patient pressure for antibiotics are associated with inappropriate prescribing

(Mangione-Smith et al., 1999). Interactional conduct was found to influence these perceptions

strongly. Two studies found that patients (or in pediatric contexts, parents) who present their

concern with a 'candidate diagnosis' are frequently perceived to want antibiotic treatment for the

condition, and that this is associated with increased rates of inappropriate prescribing (Stivers et

al., 2003; Mangione-Smith et al., 2006). Parents' resistance to a non-antibiotic treatment plan

was also found to have the same effect (Mangione-Smith et al., 2006).

Physician behaviors were also found to be influential in this process. When physicians explicitly

ruled out antibiotic treatment (e.g., "This is something that antibiotics won't fix"), patients'

resistance to the treatment plan was enhanced (Mangione-Smith et al., 2006). On the other

hand, 'online commentary' about physical exam findings that was reassuring about what the

physician was encountering reduced patient resistance to the treatment plan, leading to less

inappropriate antibiotic prescriptions (Heritage and Stivers,1999; Mangione-Smith et al., 2003).

Siimilar results showing the relevance of interaction in decisions to go ahead with tympanstomy

surgery have also been reported (Kleinman et al., 1997; Boyd, 1998; Heritage et al., 2001).

9. CA as Intervention

A final application of conversation analysis in the medical field involves a return to the detail and

nuance of individual cases. In training workshops and other contexts, many providers find it

helpful and illuminating to 'work through' the particular interactional pitfalls and opportunities

that are to be found in individual case analyses. This kind of workshop activity can be effective

in one-on-one or collective sessions, and in conjunction with subsequent work with standardized

patients.

The examination of real data using CA is found by many to be a potent

experience capable of triggering changes in attitudes and clinic

practices that are beneficial for patient care.


10. Transcription Symbols

Table 6: Transcript Conventions

Symbol Example Explanation

[ C2: quite a [ while

Mo: [ yeah

Left brackets indicate the point at

which a current speaker’s talk is

overlapped by another's talk.

] C2: and i thought]

Mo: you said]

Right brackets indicate the point at

which two overlapping utterances end.

= W: that I'm aware of =

C: =Yes. Would you

confirm that?

Equal signs, one at the end of a line

and one at the beginning, indicate no

gap between the two lines.

(.4) Yes (.2) yeah Numbers in parentheses indicate

elapsed time in silence in tenths of a

second.

(.) to get (.) treatment A dot in parentheses indicates a tiny

gap, probably no more than one-tenth

of a second.

_______ What's up? Underscoring indicates some form of

stress via pitch and/or amplitude.

:: O:kay? Colons indicate prolongation of the

immediately-prior sound. The length

of the row of colons indicates the

length of the prolongation.

WORD I've got ENOUGH TO

WORRY ABOUT

Capitals, except at the beginnings of

lines, indicate especially loud sounds

relative to the surrounding talk.

.hhhh I feel that (.2) .hhh A row of h's prefixed by a dot

indicates an inbreath; without a dot,

an outbreath. The length of the row of

h's indicates the length of the in- or

outbreath.

( ) future risks and ( ) and

life ( )

Empty parentheses indicate the

transcriber’s inability to hear what

was said.

(word) Would you see (there)

anything positive

Parenthesized words are possible

hearings.

(( )) confirm that

((continues))

Double parentheses contain author's

descriptions rather than

transcriptions.

- talking about-

uh

A hyphen after a word or part of a

word indicates a cutoff or self

interruption, often done with a glottal

or dental stop.

° C2: and then° I

remember

The degree sign indicates that the talk

following it was markedly quiet or

soft.

_: or : C2: In the gy:m? If the letter(s) preceeding a colon is

underlined, it indicates the pitch

turning downwards.

>< >we were just< "Greater than" and "less than" carrots

in this order indicate that the talk

between them is rushed or

compressed.

<> > "Less than" and "greater than" carrots

in this order indicate that the talk

between them is markedly slow.

↓ or ↑ ↓are you↓ The up and down arrows mark sharp

rises or falls in pitch or may mark a

whole shift or resetting of the pitch.

# # it was in the Indicates a rasping or 'creaky' voice

quality.

£ £ it was so Indicates the speaker is smiling while

speaking.

11. Summary

This chapter provides an overview of Conversation Analysis as an approach to the study of

clinical communication. It summarizes major social science concerns, centering on the open and

creative relationship between language and context, that the perspective is designed to address,

and describes major principles of conversation analytic research and methodology. Different

levels of organizational structure in interaction are described and exemplified, and the approach

is exemplified in a detailed treatment of an exchange between a patient and clinician about

lifestyle issues.

12. ReferencesBoyd E., Heritage J. (2006). “Taking the history: Questioning during comprehensive history

Taking.” In: Heritage J., Maynard D., Ed, Communication in Medical Care: Interactions between

Primary Care Physicians and Patients. Cambridge, UK: Cambridge University Press: 151-184.

Boyd E. A. (1998). “Bureaucratic authority in the "company of equals:" The interactional

management of medical peer review.” American Sociological Review 63(2): 200-224.

Byrne P.S., Long B.E.L. (1976). Doctors talking to patients: A study of the verbal behaviours of

doctors in the consultation. London: Her Majesty's Stationary Office.

Drew P. (1997). “'Open' class repair initiators in response to sequential sources of trouble in

conversation.” Journal of Pragmatics 28: 69-101.

Drew P., Heritage J., Eds. (1992). Talk at work: Language use in institutional and work-place

settings. Cambridge, UK: Cambridge University Press.

Haakana M. (2001). “Laughter as a patient's resource: Dealing with delicate aspects of medical

interaction.” Text 21(1): 187-219.

Halkowski T. (2006). Realizing the illness: Patients' narratives of symptom discovery. In:

Heritage J., Maynard D., Ed, Communication in medical care: Interactions between primary care

physicians and patients. Cambridge, UK: Cambridge University Press, 86-114.

Heath, C. (1992). The delivery and reception of diagnosis and assessment in the general

practice consultation. In Drew P., and Heritage J., Ed, Talk at Work. Cambridge, UK: Cambridge

University Press, 235-267.

Heritage J. (1984). Garfinkel and ethnomethodology. Cambridge, UK: Polity Press.

Heritage J. (1998). Oh-prefaced responses to inquiry. Language in society 27(3): 291-334.

Heritage J. (2008). Conversation analysis as social theory. In: Turner B., Ed, The new Blackwell

companion to social theory. Oxford, UK: Blackwell.

Heritage J., Boyd E.A., Kleinman L. (2001). “Subverting criteria: The role of precedent in

decisions to finance surgery.” Sociology of Health and Illness 23(5): 701-728.

Heritage, J., Maynard, D.W. (2006). “Problems and prospects in the study of physician-patient

interaction: 30 years of research.” Annual Review of Sociology 32: 351-374.

Heritage J., Robinson J.D., Elliott M., Beckett M., Wilkes M. (2007). “Reducing patients' unmet

concerns: The difference one word can make.” Journal of General Internal Medicine 22: 1429-

1433.

Heritage J., Sefi S. (1992). “Dilemmas of advice: Aspects of the delivery and reception of advice

in interactions between health visitors and first time mothers.” In: Drew P., Heritage J.,Ed, Talk

at work. Cambridge, UK: Cambridge University Press, 359-417.

Heritage J., Stivers T. (1999). “Online commentary in acute medical visits: A method of shaping

patient expectations.” Social science and medicine 49: 1501-1517.

Jefferson G. (1979). “A technique for inviting laughter and its subsequent

acceptance/declination.” In: Psathas G., Ed, Everyday language: Studies in ethnomethodology.

New York: Irvington Publishers, 79-96.

Jefferson G. (1985). “An exercise in the transcription and analysis of laughter.” In: Teun A. Dijk

(Ed), Handbook of discourse analysis Volume 3. New York: Academic Press, 25-34.

Kleinman L., Boyd E., Heritage J. (1997). “Adherence to prescribed explicit criteria during

utilization review: An analysis of communications between attending and reviewing physicians.”

Journal of the American Medical Association 278(6): 497-501.

Lerner G. (2003). “Selecting next speaker: The context sensitive operation of a context-free

organization.” Language in Society 32: 177-201.

Mangione-Smith R., Elliott M.N., Stivers T., McDonald L.L., Heritage J. (2006). “Ruling out the

need for antibiotics: Are we sending the right message? Archives of Pediatric and Adolescent

Medicine 160: 945-952.

Mangione-Smith R, McGlynn E., Elliott M.N., Krogstad P., Brook R.H. (1999). “The relationship

between perceived parental expectations and pediatrician antimicrobial prescribing behavior.”

Pediatrics 103(4): 711-718.

Mangione-Smith R , Stivers T., Elliott M., McDonald L., Heritage J. (2003). “Online commentary

during the physical examination: A communication tool for avoiding inappropriate prescribing?”

Social Science and Medicine 56: 313-320.

Maynard D. (1992). “On clinicians co-implicating recipients' perspective in the delivery of

diagnostic news.” In: Drew P., Heritage J., Ed, Talk at work: Social interaction in institutional

settings. Cambridge, UK: Cambridge University Press, 331-358.

Maynard D. (1996). “On 'realization' in everyday life.” American Sociological Review 60(1): 109-

132.

Maynard D. (2003). Bad news, good news: Conversational order in everyday talk and clinical

settings. Chicago: University of Chicago Press.

Mishler E. (1984). The discourse of medicine: Dialectics of medical interviews. Norwood NJ:

Ablex.

Peräkylä A. (1998). “Authority and accountability: The delivery of diagnosis in primary health

care.” Social Psychology Quarterly 61(4): 301-320.

Robinson J.D. (2003). “An interactional structure of medical activities during acute visits and its

implications for patients' participation.” Health Communication 15(1): 27-57.

Robinson J.D. (2006). “Soliciting patients' presenting concerns.” In: Heritage J., Maynard, D.,

Ed, Communication in Medical Care: Interactions between Primary Care Physicians and Patients.

Cambridge UK: Cambridge University Press, 22-47.

Robinson J.D., Heritage J. (2005). “The structure of patients’ presenting concerns: The

completion relevance of current symptoms.” Social Science and Medicine 61: 481-493.

Robinson J. D., Stivers T. (2001). “Achieving activity transitions in primary-care encounters:

From history taking to physical examination.” Human Communication Research 27(2): 253-298.

Sacks H. (1984). “On doing 'Being Ordinary'.” In: Atkinson J.M., Heritage J., Ed, Structures of

social action. Cambridge UK: Cambridge University Press, 413-429.

Sacks H. (1992) [1964-72]. Lectures on conversation (2 Vols.). Oxford: Basil Blackwell.

Schegloff E. A. (1992). “Repair after next turn: The last structurally provided defence of

intersubjectivity in conversation.” American Journal of Sociology 95(5): 1295-1345.

Schegloff E. A. (2006). “Interaction: The infrastructure for social institutions, the natural

ecological niche for language and the arena in which culture is enacted. In: Enfield N.J.,

Levinson N.C., Ed, The roots of human sociality: Culture, cognition and interaction. New York:

Berg, 70-96.

Schegloff E. A. (2007). Sequence organization in Interaction: A Primer in Conversation Analysis

Volume 1. Cambridge, UK:, Cambridge University Press.

Stivers, T. (2002). “Presenting the problem in pediatric encounters: ‘Symptoms only’ versus

‘Candidate Diagnosis’ Presentations.” Health Communication 14(3): 299-338.

Stivers, T. (2005). “Parent resistance to physicians’ treatment recommendations: One resource

for initiating a negotiation of the treatment decision. Health Communication 18(1): 41-74.

Stivers, T. (2007). Prescribing under pressure: Parent-physician conversations and antibiotics.

New York: Oxford University Press.

Stivers T., Mangione-Smith R., Elliott M.N., McDonald L., Heritage J. (2003). “Why do physicians

think parents expect antibiotics? What parents report vs what physicians perceive.” The Journal

of Family Practice 52(2): 140-148.

13. Author Biography

John Heritage, PhD’s research focuses on the sphere of social organization that Erving

Goffman calls the "interaction order." This involves looking at social interaction from the point of

view of how it is constructed; the social, cultural and psychological factors that impact its

implementation; and its impact on social outcomes, including the distribution of goods and

services and the (re-)production of social structure.

Currently his work is concentrated on three broad areas. First there is the interaction order

itself, which he approaches as a conversation analyst. Here his recent work has focused on ways

in which persons claim (and defer to) authority in interaction, and the identities that are invoked

and validated in this way.

Dr. Heritage also does research on interaction in political arenas: this work includes the analysis

of political speeches and audience reactions to them, a number of works on the news interview

as a genre of political communication and, most recently, a historical study of presidential news

conferences over the past 50 years.

The third, and largest, part of his current research program focuses on interaction in medicine.

Dr. Heritage has published a number of papers on interactions between new mothers and

community health nurses, on decision-making in health care contexts including surgery and

antibiotics prescribing, and on social interaction in general primary care. His current projects

include research on interventions to improve cancer screening rates, communication within

primary care teams, and experimental interventions to test specific changes in the ways

physicians communicate with patients. Dr. Heritage is also closely involved in studies of

antibiotics prescribing, and methods of intervening to alleviate chronic pediatric pain.

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Conversation Analysis · perspectives stress four main features of actions that pose immensely challenging issues for the ... The contextual variation (and specification) of action